Situation Karen is an 87-year old female with advanced breast…

Situation
Karen is an 87-year old female with advanced breast cancer with extensive metastasis. She was brought to the hospital via ambulance and was treated for dehydration and uncontrollable pain. She was on a medical/oncology unit for 3 days and then transferred to inpatient hospice. Karen’s provider has written orders for admission. She is currently complaining of pain and shortness of breath. She is currently on 2 LPM via nasal cannula. Her IV was placed and she was just given morphine 2.5mg IV about 2 hours ago. Karen was turned, repositioned and oral care was provided about 30 minutes ago.
Assessment
Vital Signs: HR: 98, BP 95/65, RR 28, SpO2 92% on 2 LPM per nasal cannula, T 37◦C
General Appearance: Frail, very thin and pale with mild dyspnea. Appears comfortable overall.
Integumentary: Skin breakdown in peri area and coccyx.
Cardiovascular: Sinus rhythm is S1 and S2 audible. No murmurs.
Respiratory: Crackles in both lung fields. Mild dyspnea noted secondary to ascites.
GI: Bowel sounds hypoactive, abdomen firm and distended with positive fluid wave.
GU: Voiding dark concentrated urine. Incontinent, some skin breakdown noted.
Extremities: Decreased movement and strength in all extremities.
Neurological: Pupils equal, round, and minimally reactive to light. Responds to her name only.
IVs: 20-gauge peripheral catheter intact in right arm with D5 ½ NS infusing at 30mL/hour and morphine infusing at 1mg/hr.
Fall Risk: High-risk
Pain: No grimacing, moaning, clenched mouth, restlessness, sighing or crying noted at this time.
Orders
Initial Healthcare Provider Orders
Admit to inpatient hospice bed
Diagnosis: Advanced breast cancer with extensive metastases to bones, brain and liver
Do Not Resuscitate
Nothing by mouth
Vital signs every 4 hours
Complete bedrest
Oxygen at 2 LPM via nasal cannula; titrate as needed for dyspnea
Dextrose 5% in 1⁄2 NS at 30 mL/hour
Morphine sulfate per continuous IV infusion at 1 mg/hour
Morphine sulfate 5 mg IV every 2 hours prn for breakthrough pain, call healthcare provider if pain not relieved
Lorazepam 1 mg IV every 4 hours prn for anxiety
Haloperidol 5 mg IM two times every day
Glycopyrrolate 0.2 mg IV every 4 hours
End-of-life comfort measures
Apply barrier cream to skin after each bowel and bladder incontinence
What does comfort care mean to you? Does Karen need head to toe assessment?